Citation Nr: 1452841
Decision Date: 12/01/14 Archive Date: 12/10/14
DOCKET NO. 12-10 299 ) DATE
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On appeal from the
Department of Veterans Affairs Regional Office in Wilmington, Delaware
THE ISSUE
Entitlement to service connection for the cause of the Veteran's death.
ATTORNEY FOR THE BOARD
Betty Lam, Associate Counsel
INTRODUCTION
The Veteran served on active duty from November 1967 to October 1970. He died in October 1998. The Appellant is the Veteran's surviving spouse.
This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Regional Office (RO) in Wilmington, Delaware, in which the RO reopened and denied on the merits the claim of entitlement to service connection for the cause of the Veteran's death.
As a procedural matter, the Board incorporates by reference its April 2014 discussion explaining the proper identification and adjudication of the Appellant's claim of service connection for the cause of the Veteran's death. See Board Remand, p. 2 (April 23, 2014). This matter was remanded to the Agency of Original Jurisdiction (AOJ) for additional development, and the case is once again before the Board.
The Board notes that, in addition to the paper claims file, there is also a Virtual VA and VBMS paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals an October 2014 report of contact from the Appellant stating that she had received and reviewed the Supplemental Statement of the Case (SSOC) and does not have any additional evidence to submit regarding the appeal. This evidence has been considered by the Board in adjudicating this matter. The remaining documents in VBMS and Virtual VA paperless claims file are either duplicative in the paper claims file or irrelevant to the issue on appeal.
The case is REMANDED to the AOJ. VA will notify the Appellant if further action is required.
REMAND
Although the Board regrets any further delay, a remand is necessary to ensure that due process is followed, and that there is a complete record upon which to decide the Appellant's claim so that she is afforded every possible consideration.
The Appellant seeks to establish service connection for the cause of the Veteran's death. She maintains, in essence, that the Veteran's PTSD, which he suffered during his lifetime, has been causally linked to his active duty service. She contends that the Veteran's PTSD caused him to abuse alcohol, which, in turn, caused the fatal conditions that led to his death.
Upon review, the service personnel records confirmed that the Veteran was stationed in the Republic of Vietnam from February 21, 1970 to November 10, 1970, and that his military occupational specialties included lineman and senior wireman. However, the information of record also reveals that the Veteran experienced problems related to alcoholism during service, before his tour of duty in the Republic of Vietnam. See, e.g., July 1971 Administrative Decision (noting the Veteran's report that he was charged with drunk driving and given an Article 15 while stationed in Germany in 1968).
The medical records pertaining to treatment at the Coatesville VA Medical Center (VAMC), dated through October 1997, reveal that the Veteran had a long history of alcohol abuse and suffered a possible alcohol-induced fall in August 1997, which resulted in laceration of the forehead and intracranial hemorrhage.
A March 1998 VA examination report referred by history to the Veteran's complaints of chronic sleeping problems, disturbances in mood, and chronic alcoholism since the Veteran's return home from service. At that time, the Veteran related that he was seen by a psychologist, who had prescribed him medication around 1971, when he experienced symptoms of hallucinations of Vietnam. He indicated that he had received no other treatment until 1992, when he was seen for severe stomach hemorrhage as a result of alcoholism. Reportedly, the Veteran underwent a surgical procedure of his stomach and esophageal area, and was diagnosed with chronic cirrhosis of the liver. The Veteran made reference to an evaluation he had received for a liver transplant at the University of Pittsburgh Medical Center. The diagnosis was of PTSD secondary to military service, but the symptoms were somewhat diffused and contaminated by the effects of the Veteran's (post-service) head injury. According to the VA examiner, the neurological impairment caused by the (post-service) fall had "complicated" the overall clinical picture; however, it was quite obvious that the Veteran suffered from a chronic problem in regard to PTSD.
An October 1998 Northern Maine Medical Center (emergency room) report reveals that the Veteran was admitted for alcohol intoxication. The physician noted that the Veteran was on medication for depression and stomach problems, that the Veteran's health continued to decline while he was hospitalized, and that the Veteran died in October 1998. The Death Discharge Summary report listed (1) a primary diagnosis of hepatorenal syndrome with metabolic acidosis and hyperkalemia; and (2) a secondary diagnosis of fulminant hepatic failure hepatitis C with liver cirrhosis, gastrointestinal bleeding, respiratory failure, alcohol abuse, history of esophageal varices, grade IV coma secondary to liver failure, thrombocytopenia, enterococcus, hypokalemia and hypernatremia. According the physician, the Veteran's brother related that the Veteran had a problem with alcoholism since the Vietnam War.
A VA medical opinion was provided in August 2014, in order to determine the etiology of the Veteran's alcohol abuse (and consumption), and whether the Veteran's acquired psychiatric disorder, to include PTSD, caused or contributed to cause his alcohol abuse (and consumption), which in turn may have caused or contributed to cause the Veteran's death. The VA psychologist noted that the paper claims file, private medical records, VA medical records, and the service medical records were not available for review, noting that there were only two documents in VBMS. The psychologist opined that while the evidence was very thin, it is at least as likely as not that the diagnosis of PTSD was either incurred in or otherwise related to the Veteran's military service. However, the psychologist explained that it was not possible to render an opinion regarding the likelihood of whether the Veteran's PTSD caused or aggravated his alcohol abuse given the lack of information available.
In view of the foregoing, the Board is of the judgment that a remand is warranted to accord the VA psychologist an opportunity to provide a medical opinion based upon a complete review of all of the medical and lay evidence contained in the paper claims file, together with a review of VBMS paperless file, for the purposes of rendering an opinion as to the etiology of the Veteran's alcohol abuse; and whether the Veteran's PTSD caused or contributed to cause to his alcohol abuse, which in turn may have caused or contributed to cause of the Veteran's death.
Accordingly, the case is REMANDED for the following action:
1. The AOJ should request copies of any outstanding private treatment records for the period of 1992 to 1998 at the University of Pittsburgh Medical Center (referenced in the March 1998 VA examination) and from Dr. N.U.K. of Neurosurgery, who treated the Veteran for his alcohol-induced fall in August 1997 (referenced in the Christiana Health Care record received in May 2002); and VA treatment records from the Richmond VAMC for treatment of brain trauma (referenced in the October 1997 report of contact) with the assistance of the Appellant. All necessary authorizations should be requested. Any records received must be associated with the claims file. All efforts to obtain private and VA records should be fully documented, and the VA facility must provide a negative response if records are not available.
2. After any additional evidence has been associated with the claims file, return the entire claims file, both paper and paperless, to the VA examiner who prepared the April 2014 medical opinion report, or (if unavailable) to another qualified medical examiner, to provide a medical opinion addressing the following questions:
a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's abuse of alcohol (alcoholism) was caused by, or is a symptom of, his PTSD?
b) If the answer to (a) is "No," is it at least as likely as not (a 50 percent or greater probability) that the Veteran's PTSD aggravated (i.e., permanently worsened) his abuse of alcohol (alcoholism)? In this context, "aggravation" has occurred when it has been medically determined that the alcohol abuse (alcoholism) has undergone an identifiable permanent increase in its severity that was proximately due to or the result of the Veteran's PTSD.
c) If the answer to either (a) or (b) is "Yes," is it at least as likely as not (50 percent or greater probability) that the Veteran's abuse of alcohol (alcoholism) caused or contributed to cause the fatal conditions of (1) hepato-renal syndrome with metabolic acidosis and hyperkalemia, (2) fulminant hepatic failure, and (3) hepatitis C positive with liver cirrhosis?
d) If the answers to (a) and (b) are "No," is it at least as likely as not (50 percent or greater probability) that the Veteran's abuse of alcohol (alcoholism) began during service from voluntary and willful drinking to excess, which had continued after his discharge from service?
e) If the answer to (d) is "Yes," is it at least as likely as not (50 percent or greater probability) that the fatal conditions of (1) hepato-renal syndrome with metabolic acidosis and hyperkalemia, (2) fulminant hepatic failure, and (3) hepatitis C positive with liver cirrhosis, are a result of, or were caused by, the Veteran's own abuse of alcohol during service (i.e., primary alcoholism acquired in service) that continued thereafter?
In answering each of the above questions, the examiner should consider the Veteran's statements regarding his pattern of drinking and amount of alcohol consumption before, during, and after his tour of duty in the Republic of Vietnam, and should also consider the statements from the Veteran's wife and brother that the Veteran had a problem with alcoholism since the Vietnam War. See February 2002 Veteran's Wife Statement; March 1998 VA examination report; and October 1998 Northern Maine Medical Center Death Discharge Summary Report.
The reasons and bases for each opinion are to be fully explained with a complete discussion of the evidence of record and sound medical principles, including the use of any medical literature, which may reasonably explain the medical analysis in the study of this case.
4. Then, the AOJ should re-adjudicate, on the merits, the issue of entitlement to service connection for the cause of the Veteran's death. If the determination remains adverse to the Appellant, the Appellant and her representative should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review, if otherwise in order.
The Appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999).
This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013).
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DEBORAH W. SINGLETON
Veterans Law Judge, Board of Veterans' Appeals
Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).